© 2009 Schattauer GmbH, Stuttgart Consensus Document Management of Antithrombotic Therapy in Atrial Fibrillation Patients Presenting With Acute Coronary Syndrome and/or Undergoing Percutaneous Coronary Intervention/ Stenting A Consensus Document of the European Society of Cardiology Working Group on Thrombosis, endorsed by the European Heart Rhythm Association [EHRA] and the European Association of Percutaneous Cardiovascular Interventions [EAPCI] Gregory Y H Lip1*; Kurt Huber2**; Felicita Andreotti3***; Harald Arnesen4***; K Juhani Airaksinen5***; Thomas Cuisset6***; Paulus Kirchhof7***; Francisco Marín8*** University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham United Kingdom; 23rd Department of Medicine, Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna, Austria; 3Department of Cardiovascular Medicine, “A Gemelli” University Hospital, Rome, Italy; 4Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway; 5Department of Medicine, Turku University Hospital, Turku, Finland; 6Department of Cardiology, CHU Timone, Marseille, France; 7Department of Cardiology and Angiology, Universitätsklinikum Münster, Münster, Germany; 8Department of Cardiology Hospital Universitario Virgen de la Arrixaca, Ctra Madrid-Cartagena s/n, Murcia, Spain Document Reviewers: A Rubboli, A J Camm, H Heidbuchel, E Hoffmann, N Reifart, F Ribichini, F Verheugt Summary There remains uncertainty over optimal antithrombotic management strategy for patients with atrial fibrillation (AF) presenting with an acute coronary syndrome and/or undergoing percutaneous coronary intervention/stenting Clinicians need to balance the risk of stroke and thromboembolism against the risk of recurrent cardiac ischaemia and/or stent thrombosis, and the risk of bleeding This consensus document comprehensively reviews the published evidence and presents a consensus statement on a ‘best practice’ antithrombotic therapy guideline for the management of antithrombotic therapy in such AF patients Keywords Arial fibrillation, antithrombotic therapy, acute coronary syndrome, percutaneous coronary intervention, stenting, warfarin Thromb Haemost 2009; 102: ■■■ timated prevalence of AF in 1–2% of the population (4, 5), one to two million anticoagulated patients in Europe are candidates for coronary revascularisation, often in the form of percutaneous coronary interventions (PCI), usually including stents The long-term results of stent usage have been blighted by the dual problem of in stent restenosis (ISR) and stent thrombosis In particular, the increasing use of drug-eluting stents (DES) to minimise ISR necessitates long-term dual antiplatelet therapy with aspirin plus a thienopyridine (at present most frequently clopidogrel) to reduce the risk of early and late stent thrombosis Combined aspirin-clopidogrel therapy, however, is less effective Preamble Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia, with a substantial risk of mortality and morbidity from stroke and thromboembolism Antithrombotic therapy is central to the management of AF patients, with oral anticoagulation (OAC) with the vitamin K antagonists being recommended as thromboprophylaxis in patients with AF at moderate-high risk of thromboembolism (1) Approximately 70–80% of all patients in AF have an indication for continuous OAC, and coronary artery disease co-exists in 20–30% of these patients (2, 3) With an esCorrespondence to: Prof G Y H Lip University of Birmingham Centre for Cardiovascular Sciences City Hospital, Birmingham B18 7QH, United Kingdom Tel.: +44 121 5075080, Fax: +44 121 554 4083 E-mail: g.y.h.lip@bham.ac.uk * Chair of the Task Force, ** Co-Chair of the Task Force, *** Member of the Task Force Received: August 20, 2009 Accepted: September 12, 2009 Prepublished online: September 30, 2009 doi:10.1160/TH09-08-0580 Consensus Document of the ESC Working Group on Thrombosis declare a previous relationship with industry that might be perceived as relevant to guideline development This consensus document is intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches for management, and reflect a consensus of expert opinion after a thorough review of the available, current scientific evidence with the aim of improving patient care The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient Literature searches were conducted in the following databases: PubMed/MEDLINE and the Cochrane Library (including the Cochrane Database of Systematic Reviews and the Cochrane Controlled Trials Registry) Searches focused on English-language sources and studies in human subjects Articles related to animal experimentation were cited when the information was important to understanding pathophysiological concepts pertinent to patient management and comparable data were not available from human studies Additional information was requested from the authors where necessary Classification of Recommendations and Level of Evidence are expressed in the ACC/ AHA/ESC format as follows and described in Supplementary Table (available online at www.thrombosis-online.com) Recommendations in this consensus document are evidence-based and derived primarily from published data In the majority of cases, these recommendations represent level of evidence C due to lack of prospective randomised studies and/or registries in preventing stroke compared to OAC alone (6) and OAC alone is insufficient to prevent stent thrombosis (7) The management of AF patients presenting with an acute coronary syndrome (ACS) poses similar management complexities ACS patients presenting with acute ST elevation myocardial infarction (STEMI) are increasingly managed with primary PCI with additional combined antithrombotic therapy regimes Those presenting with non-ST elevation acute myocardial infarction (NSTEMI) are also managed with combined antithrombotic therapy, and frequently an early invasive revascularisation strategy is recommended by guidelines and more commonly used Current guidelines for ACS and/or PCI broadly recommend the use of aspirin-clopidogrel combination therapy after ACS (12 months irrespective of PCI), and after a stent (4 weeks for a bare metal stent, up to 12 months for a DES) (8, 9) Clearly, in subjects with AF at moderate-high risk of stroke [essentially CHADS2 score of = medium risk, >1 = high risk, vide infra for acronym], where there is the requirement for long-term OAC, there is the need to balance stroke prevention against stent thrombosis following PCI-stenting, versus the harm of bleeding with combination antithrombotic therapy Thus, in AF patients who present acutely with an ACS – as well as those who undergo elective PCI-stenting – who are already on OAC, the management now would in theory lead to so-called ‘triple (oral) therapy’ consisting of dual oral antiplatelet inhibition plus OAC, with the potential harm of bleeding It has to be stated clearly that the use of DES of first and second generation, due to the prolonged need of dual antiplatelet therapy, should be avoided in patients with an indication for long-term OAC Unfortunately, this situation is not always known when stents are implanted or might become evident after stent implantation Moreover, there is a lack of published evidence on what is the optimal management strategy in such AF patients Current published clinical guidelines on antithrombotic therapy use in AF and PCI not adequately address this issue (8–14) (see Supplementary Table available online at www.thrombosis-online com) In recognising this deficiency, the Working Group on Thrombosis of the European Society of Cardiology (ESC) convened a Task Force, with representation from the European Heart Rhythm Association (EHRA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) with the remit to comprehensively review the published evidence and to publish a consensus document on a ‘best practice’ antithrombotic therapy management guideline for management of antithrombotic therapy in AF patients presenting with ACS and/or undergoing PCI-stenting The Task Force was charged with the task of performing an assessment of the evidence and acting as an independent group of authors to develop or update written recommendations for clinical practice The ESC Committee for Practice Guidelines have made every effort to avoid any actual, potential, or perceived conflict of interest that might arise as a result of an outside relationship or personal interest of the writing committee Specifically, all members of the Writing Committee and peer reviewers of the document were asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest Writing committee members were also encouraged to Overview of pathophysiology of thrombogenesis in AF and in ACS/PCI/stents as relevant to clinical observations 2.1 Thrombogenesis in AF in relation to stroke and other systemic thromboembolism Subjects with non-valvular AF who are not receiving antithrombotic drugs have an annual rate of ischaemic stroke or other systemic thromboembolism (TE) of 5%, compared to 0.5–1% in age-matched controls without AF (1) The risk of TE with AF increases over five-fold in the presence of rheumatic heart disease, especially mitral valve stenosis Rheumatic heart disease is observed in 15% of Western AF patients, but this is even a larger problem world-wide Approximately one in three patients with AF not receiving anticoagulants will develop an ischaemic stroke in their lifetime, with roughly two-thirds being cardioembolic and one-third being atherothrombotic (1) Cardioembolic strokes are more disabling than atherothrombotic strokes, with a higher early mortality rate (1, 15) The risk of TE is similar among subjects with paroxysmal, persistent or permanent AF, and is increased by the presence of clinical risk factors, especially where there is a history of prior stroke or mitral stenosis/prosthesis (1) The CHADS2 score (Congestive heart failure; Hypertension; Age; Diabetes; previous ischemic Stroke) is the simplest and most commonly used schema for predicting the risk of TE in patients with non-valvular AF, whereby patients with a score of ≥2 are ‘high risk’ and merit anticoagulation with warfarin (16) (see Table 1) Excellent overviews of stroke risk factors and published stroke risk stratifi- Consensus Document of the ESC Working Group on Thrombosis Table 1: Clinical factors associated with an increased risk for stroke/thromboembolism and an increased risk of severe bleeding in AF patients Note that most factors pose patients at risk for both types of events In AF patients in general, thromboembolic events (strokes) are approximately one magnitude more likely than severe bleeds Less validated factors are given in brackets Adapted from Kirchoff et al Europace 2009; 11: 860–885 TIA transient ischaemic attack, TE thromboembolism, GI gastrointestinal, MI myocardial infarction, LVEF left ventricular ejection fraction Risk factors for thromboembolism Bleeding risk factors Previous stroke, transient ischemic attack, or embolism Cerebrovascular disease, Age = 75 years (Age 65 to 74 y) Advanced age (>75 years) Heart failure or moderate-severe left ventricular dysfunction on echocardiography [eg Ejection fraction =40%] (Vascular disease) History of myocardial infarction or ischemic heart disease Hypertension Uncontrolled hypertension Diabetes mellitus ? (Female gender) ? Mitral stenosis Prosthetic heart valve Anaemia (renal dysfunction (stage III-V)) (Renal dysfunction [stage III-V]) History of bleeding Concomitant use of other antithrombotic substances such as antiplatelet agents blood constituents’ are well described, involving haemostasis and platelet activation, as well as fibrinolysis, inflammation and growth factors (23, 29–31) This triad of abnormalities increasing the propensity to thrombogenesis in AF has led to AF being described as a prothrombotic or hypercoagulable state, a concept first proposed in 1994 (32) Of note, many circulating prothrombotic biomarkers, including those related to inflammation, have prognostic implications in AF (33–35) The relative role of coagulation versus platelet activation in the pathogenesis of TE in patients with AF can roughly be inferred from the results of antithrombotic drug interventions that have been tested in randomised clinical trials Among non-valvular AF patients, the relative risk reduction (RRR) for stroke that is achieved with moderate intensity OAC [international normalised ratio (INR) = 2–3] compared to placebo is approximately 65%, as opposed to the 20% RRR achieved with aspirin versus placebo (1, 36) Consistently, moderate intensity OAC produces a RRR for stroke of 40% compared to aspirin, and of 30% compared to aspirin + clopidogrel (6, 36) Interestingly, among medium-high risk non-valvular AF patients not eligible to take warfarin, aspirin + clopidogrel was superior to aspirin alone for stroke prevention (37) Taken together, these results indicate that inhibition of coagulation remains the mainstay in preventing AF-related TE The lesser but significant role of platelets – best inhibited by a combined antiplatelet drug regimen – is presumably related to the prominent involvement of platelets in the pathogenesis of atherothrombotic (that is, non-cardioembolic) events cation schemata have been published by the Stroke in AF Working Group (17, 18), as well as by the UK National Institute for Health and Clinical Excellence (NICE) (19) Risk factors for bleeding and bleeding risk assessment scores have also been recently reviewed (20, 21), but it is worth remembering that as stroke risk increases, bleeding risk also increases, often leading to discontinuation of OAC therapy (22) Increasing evidence suggests that the thrombogenic tendency in AF is related to several underlying pathophysiological mechanisms, which can be discussed in relation to Virchow’s triad for thrombogenesis (23) The type of thrombus in AF is mainly fibrin-rich where platelets play a smaller role, consistent with the superior prophylactic effect of OAC in comparison with antiplatelet therapy for stroke prevention in AF (1, 6, 23, 24) ‘Abnormal changes in blood flow’ are evident by stasis in the left atrium (LA), and seen as spontaneous echocontrast on transesophageal echocardiography (TEE) The loss of synchronous atrial systolic function, with sluggish/stagnant flow, results in stasis, mostly within the LA appendage Indeed, residual thrombus within the LA appendage can be detected by TEE in over 40% of AF patients with acute TE (25) ‘Abnormal changes in vessel wall’ usually refer to underlying structural heart disease (which can be observed in about 70% of AF patients) that includes LA enlargement, poor systolic and/or diastolic left ventricular (LV) function, mitral annulus calcification, etc Ultrastructurally, a ‘prothrombotic’ LA endocardial surface has been described, with endocardial denudation and oedematous/fibroelastic infiltration of the extracellular matrix (23, 26) Moreover, sources of TE other than the LA appendage (such as LA, LV, ascending aorta, carotid and intracerebral arteries) may exist in AF patients (23) There is also increased local expression in the dysfunctional atrial endocardium of prothrombotic molecules, such as tissue factor (27) and von Willebrand factor (VWF) (28) The third component of Virchow’s triad, that is, ‘abnormal changes in Thrombogenesis in ACS/PCI/stenting The ACS, which include unstable angina, NSTEMI and STEMI, share common pathophysiological processes that are characterised by coronary plaque disruption/erosion with superimposed thrombus formation, leading to myocardial ischaemia Consensus Document of the ESC Working Group on Thrombosis by an antiplatelet drug combined with OAC (12, 42), and among ACS patients, aspirin + clopidogrel vs aspirin alone given for 9–12 months reduces the rate of MACE from 11% to 9%, while increasing major bleeds from 2.7% with aspirin alone to 3.7% with the dual antiplatelet drug regimen (42) Yet, in men at high risk of cardiovascular disease (CVD) (43) and among patients with manifest CAD, the RRR of MACE with aspirin therapy alone is similar to that achieved with OAC alone (about 20%) (44) This suggests that the plaque rupture (that presumably triggers most spontaneous ACS) induces a thrombogenic state that involves both platelets and coagulation Indeed, aspirin + OAC (whether warfarin or a direct thrombin inhibitor) are superior to aspirin alone in the management of ACS patients (44) and, in theory, both are not inferior to dual antiplatelet therapy (45) Additionally, procoagulant polymorphisms of the Factor II, Factor V and PAI-1 genes but none of the platelet gene polymorphism explored to date have shown significant associations with clinically manifest CAD (46) Patients with ACS at high risk of complications, especially those with STEMI and high-risk NSTEMI patients, derive significant benefit from urgent PCI, in terms of reduced major adverse cardiovascular events (MACE) (12) PCI with stenting requires not only dual antiplatelet therapy with aspirin and a thienopyridine ADP-receptor antagonist, but often an “upgraded” triple antiplatelet regimen in the periprocedural phase, through the administration of a glycoprotein IIb/IIIa antagonist Moreover, in patients receiving DES, re-endothelialisation of the inner surface of stents is slow, which explains the longer need for combined antiplatelet therapy due to the pro-thrombogenic surface of non-reendothelised stents with DES versus bare metal stents (BMS) Thrombogenesis in ACS/PCI-stenting In most cases, ACS is ultimately brought about by localised damage of the endothelial surface of the coronary arteries, usually as a consequence of an underlying atherosclerotic lesion (38) In about 25% of cases the damage consists of a superficial erosion or denudation of the endothelial cells covering the atherosclerotic plaque, whereas in about 75% it is caused by plaque rupture PCI results in additional ‘trauma’ to the vessel wall, that triggers local prothrombotic activation The implantation of a stent to secure the initial dilatation and prevent restenosis gives rise to further (and often chronic) prothrombotic/proinflammatory reaction(s) towards this ‘foreign substance’ (39) With the use of DES, covered with antiproliferative agents aimed at inhibiting restenosis but also delaying re-endothelialisation, this prothrombotic/proinflammatory activation will last for months and years and may contribute to stent thrombosis even after one year (40, 41) Chronic activation of coagulation may also be present, as microscopic examination has reported fibrin deposition at the stent ends (40, 41) Thromboembolic risk in stable and acute CAD, with and without PCI treatment The annual rate of MACE during the first year after an ACS is in the order of 9–10%, with most events occurring in the first three months (47) The risk is considerably lower for patients with stable CAD, with an estimated 2% annual incidence of MACE (48) As mentioned above, PCI with stenting compared to balloon angioplasty alone has markedly reduced the rates of restenosis, but is associated with a risk of stent thrombosis The latter has received special attention in virtue of its high associated mortality and morbidity (49) In randomised trials, the incidence of ACS attributable to definite, possible or probable stent thrombosis (using the Academic Research Consortium definitions [50]) is approximately 0.5–1% per year, for up to four years after PCI (“definite” = with angiographic or autopsy evidence; “probable” = related to stented vessel or to unexpected death within 30 days of PCI; “possible” = related to unexpected sudden death beyond 30 days of PCI) (51, 52) Most stent thromboses occur early (1 year) (49–51) The incidence of early stent thrombosis (10-fold increase of stent thrombosis (49) Recent data also show that polymorphisms in the cytochrome P450 gene, that regulates thienopyridines metabolic activation, are significantly linked with lower antiplatelet response to certain therapies and with an approximately threefold higher incidence of stent thrombosis (54) These observations make dual antiplatelet drug treatment mandatory for all contemporary PCI-treated patients, with durations ranging from four weeks for BMS up to one year or more for all DES Prothrombotic/proinflammatory state in ACS/PCI-stenting Under normal circumstances the endothelium is antithrombotic by expressing inhibitors of platelet activation, like nitric oxide (NO) and prostacyclin (PGI2), coagulation inhibitors, like tissue factor pathway inhibitor and heparan sulphate, in addition to tissue-type plasminogen activator promoting fibrinolysis However, when superficial erosions occur, the endothelium is activated towards haemostasis, becoming pro-thrombotic with expression of VWF and plasminogen activator inhibitor-1, in addition to reduced expression of NO and PGI2 (38) This promotes platelet activation which in turn can activate coagulation on the platelet surface When spontaneous or PCI-induced plaque rupture occurs, circulating blood gets in contact with the subendothelium and with constituents of the atherosclerotic plaque; thus, collagen will further increase the activation of platelets, and most importantly, tissue factor will be available for activation of coagulation (38) In a short time, a potentially occlusive thrombus may form (38) The pathogenesis of coronary thrombosis amongst patients with coronary artery disease (CAD) and in those undergoing PCI is considered to be largely platelet driven Indeed, antiplatelet therapy compared to placebo is effective in reducing the incidence of MACE in CAD (9, 14); also, PCI-related thrombosis is best prevented by a combination of antiplatelet drugs rather than Periprocedural issues It is estimated that around 5% of patients undergoing PCI require long-term OAC due to AF (55–57) Accordingly, patients with ACS and on home warfarin are significantly less likely to under- Consensus Document of the ESC Working Group on Thrombosis go coronary angiography and PCI and their waiting times for these procedures are longer than in patients not on warfarin (55) The general perception that warfarin should be discontinued a few days prior to PCI and the periprocedural INR level should be < 1.5–1.8 may contribute to these delays A simple strategy of temporary replacement of warfarin by dual antiplatelet drug therapy is not a good option, as shown by more adverse events in recent observational studies on coronary stenting (57, 58) This view is supported by data showing that non-use of oral anticoagulation markedly increases mortality in patients with AF after acute myocardial infarction (59–61) Another potential strategy is a temporary adjustment of warfarin dosing to reach a perioperative INR of 1.5–2.0 The latter has been shown to be safe and effective in the prevention of thromboembolism after orthopaedic surgery, but the low INR level is inadequate for PCI or stroke prevention in AF (1, 62) Current guidelines recommend bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) to cover the temporary discontinuation of OAC, if the risk of thromboembolism is considered high (8) These recommendations are based on circumstantial evidence and there are no large randomised trials to support the recommendations Indeed, there are no randomised trials comparing different strategies to manage long-term OAC during PCI The safety and feasibility of heparin bridging therapy has been evaluated in patients who receive long-term OAC and require interruption of OAC for elective surgery or an invasive procedure (63–67) Spyropoulos et al (64) showed a major bleeding rate of 3.3% with UFH and 5.5% with LMWH in 901 patients with bridging therapy for an elective surgical or invasive procedure Another recent study (65) reported a 6.7% incidence of major bleeding with LMWH bridging therapy in patients at risk of arterial embolism undergoing elective non-cardiac surgery or an invasive procedure, but also lower (2.9%) rates of major bleeding have been reported Reports focusing on PCI are limited, but MacDonald et al (68) reported that 4.2% of 119 patients developed enoxaparinassociated access site complications during LMWH bridging therapy after cardiac catheterisation Thus, there is some suggestion that UFH is better than LMWH for bridging to manage OAC for PCI Patients undergoing PCI require procedural anticoagulation not only to avoid thromboembolic complications, but also thrombotic complications of the intervention, and only highly selected low-risk procedures may be safe without anticoagulation (69) Periprocedural anticoagulation has traditionally been performed with UFH or more recently with LMWHs or direct thrombin inhibitors Theoretically, warfarin may also be used to facilitate PCI, since warfarin is known to increase activated coagulation time in a predictable fashion (70) Supporting this view, recent findings suggest that uninterrupted anticoagulation with warfarin could replace heparin bridging in catheter interventions with a favorable balance between bleeding and thrombotic complications (71–75) In these studies, this simple strategy was at least as safe as that of more complicated bridging therapy The incidence of bleeding or thrombotic complications was not related to periprocedural INR levels and propensity score analyses suggested that the bridging therapy may lead to increased risk of access site complications after PCI (72) Similarly, therapeutic (INR 2.1–4.8) periprocedural warfarin led to the lowest event rate with no increase in bleeding events in 530 patients undergoing balloon angioplasty through the femoral route (76) In line with these PCI studies, no major bleeding events were observed in patients randomised to therapeutic periprocedural warfarin in a small study of diagnostic coronary angiography, although all procedures were performed using transfemoral access Of importance, a median of nine days was required for INR to return to the therapeutic level in the patients where warfarin was stopped (77) Performing PCI without interrupting warfarin has several theoretical advantages Wide fluctuations in INR are known to be common and long lasting after interruption necessitating prolonged bridging therapy Secondly, warfarin re-initiation may cause a transient prothrombotic state due to protein C and S suppression (78) The fear for fatal bleedings with uninterrupted OAC may also be overemphasized, since the anticoagulant effect of warfarin can be rapidly overcome by a combination of activated blood clotting factors II, VII, IX and X or by fresh frozen plasma Finally, interruption of OAC only seems to be mandatory in coronary procedures with a relatively high risk for perforation, e.g the more aggressive interventional treatment of chronic total occlusions (75) In the light of limited data, the simple strategy of uninterrupted OAC treatment is an alternative to bridging therapy and may be most useful for the patients with high risk of thrombotic and thromboembolic complications, since OAC cessation and reinitiation may cause a transient prothrombotic state If this strategy is chosen, radial access is recommended in all patients to decrease the rate of procedural bleedings Furthermore, in planned or non-urgent procedures and when patients have a therapeutic OAC (INR 2–3), the additional use of UFH is not necessary and might potentially trigger bleeding complications This is different in patients with acute STEMI, when INR is frequently not known: in this situation, regardless of INR values, UFH should be added in moderate doses (e.g 30–50 U/kg) (76) Aspirin and clopidogrel Aspirin reduces periprocedural ischaemic complications and should be administered in all patients prior to any PCI procedures Based on randomised trials and posthoc analyses, pretreatment with clopidogrel is also recommended whenever it can be accomplished (80) Even if there are no randomised trials on the efficacy and safety of this antiplatelet policy in patients on OAC, analyses from retrospective studies also support this recommendation in this patient group (57, 72) Glycoprotein IIb/ IIIa inhibitors (GPI) There is a modest increase (2.4% versus 1.4%) in bleeding risk associated with GPI use during ACS (81) There are no safety data from clinical trials on warfarin-treated patients, since this patient group has been excluded from all randomised GPIIb/IIIa studies In ‘real-world’ clinical practice, warfarin-treated patients are less often treated with GPIIb/IIIa drugs Not surprisingly, bleeding complications seem to represent a significant limitation to the effectiveness of GPIs, as shown by the CRUSADE Registry (82) In the latter, GPI use was associated with increased in-hos- Consensus Document of the ESC Working Group on Thrombosis Reports on the incidence of stent thrombosis in patients with AF are scarce (54) and the diagnostic criteria have varied, since the uniform criteria has only recently been published (88) Stent thrombosis seems to be rare in this patient group in real-life practice, especially with triple therapy (59, 60, 97) However, a warfarin + aspirin regimen seems to be suboptimal in the prevention of myocardial infarction (60) A trend towards worse outcomes was observed in patients with AF receiving warfarin and a single antiplatelet agent (98) However, the small number of adverse events and limited information should be taken into account when considering these results At present, in patients on OAC therapy, the additional use of dual antiplatelet therapy (triple therapy) seems to be the best option to prevent stent thrombosis and thromboembolism Data on the safety of warfarin + clopidogrel combination are limited, but this combination may be an alternative in patients with high bleeding risk and/or absent risk factors for stent thrombosis In patients with very high bleeding risk, DES should be avoided (99) and balloon angioplasty (without stenting) is an option if an acceptable result can be achieved In this case OAC might be combined with aspirin or a thienopyridine ADP-receptor antagonist in the usual dose If, however, a stent is needed, BMS, especially “less thrombogenic stents” (carbon- or titanium-nitricoxide-coated stents, stents with biodegradable coating, or antibody-coated stents capturing endothelial progenitor cells may perhaps need a shorter duration of combination antiplatelet therapy (100–103) In general, DES should be avoided in patients under OAC at present However, new third generation DES seem to have accelerated re-endothelialisation and might therefore become of interest in the near future Respective registries (e.g the Italian MATRIX registry) and trials to test their usefulness are currently performed pital risk of major bleeding (13.8% versus 9.0%) and transfusions (10.8% versus 9.1%) in the patients on home warfarin treatment even if only one third of the patients underwent PCI In patients under OAC, the additional use of GPIs in the cath lab varies between 3% and 71% (57) In recent PCI studies, the GPI use was associated with a three- to 13-fold risk of early major bleeding in warfarin-treated patients (71, 72, 83) A recent analysis on 10 clinical trials assessing the efficacy and safety of various antithrombotic medications in ACS reported that new AF developed in 7% of the randomised patients during hospitalisation, and resulted in a four-fold increase in the incidence of moderate or severe bleeding in patients with NSTEMI, mainly randomised to GPI (84) Thus, there is a wide variation in the use of GPIs in warfarintreated AF patients in real-life setting In general, GPIs seem to increase major bleeding events irrespective of periprocedural INR levels and should be used with some caution in this patient group and probably avoided if use is not indicated due to massive intraluminal thrombi Furthermore, GPIs add little benefit in terms of reduction of ischaemic events in patients with stable angina and troponin-negative ACS (85, 86) Bivalirudin Increasing data for the intravenous direct thrombin inhibitor, bivalirudin, in the ACS setting are available in the setting of primary PCI and ACS (87, 88), with a similar reduction in MACE but lower bleeding events, when compared to heparin plus GPIIb/IIIa However, there are limited data on bivalirudin in AF patients, especially in the setting of concomitant anticoagulation with a OAC Access site In addition to the choice of antithrombotic strategy, vascular access site selection may also have a great impact on bleeding complications Radial artery access has been associated with a reduced risk of access site bleeding and other vascular complications in meta-analysis of randomised trials and registry studies (89–91) In line with these reports, femoral access was an independent predictor (Hazard Ratio of 9.9) of access site complications in 523 warfarin-treated patients (72) Continuing randomised trials (CURRENT substudy and RIVAL) will ultimately give an answer to the selection of access site In addition, vascular closure devices are an alternative to mechanical compression in order to achieve vascular haemostasis after femoral artery puncture, but the meta-analysis could not demonstrate significant effects on haemorrhagic or vascular complications (92) On the basis of current evidence, a radial approach should be always considered in anticoagulated patients, since haemostasis is rarely an issue with this access site Stroke The ACTIVE-W trial (6) showed that dual antiplatelet therapy cannot replace OAC in stroke prevention in patients with AF and recent observational studies on clinical practice support this conclusion also after on coronary stenting (59, 60) The incidence of stroke has rarely been reported in these studies, but triple therapy has generally been more effective than both dual antiplatelet treatment and the combination of OAC and a single antiplatelet agent (57, 59, 60, 98) With triple therapy, thromboembolic events are infrequent (57), although a much higher incidence (15.2%) has been reported in patients while on treatment with the combination of warfarin and aspirin (60) Interestingly, the ACTIVE-A trial which studied aspirin-clopidogrel combination therapy for stroke prevention in moderate-high risk patients with AF for whom OAC therapy was unsuitable, the addition of clopidogrel to aspirin reduced the risk of major vascular events (RR with clopidogrel, 0.89; 95%CI, 0.81–0.98; P=0.01), especially stroke (RR 0.72; 95%CI, 0.62–0.83; P85% of major bleeds are related to catheterisation access site High risk for bleeding has been defined as ≥2 the above criteria An bleeding risk index for outpatients based on the same risk factors has been developed for the evaluation of long-term bleeding risk in warfarin treated patients, but it is not known whether this index is also useful for the patients with concomitant need for antiplatelet therapy (109) In patients with high bleeding risk the duration of dual antiplatelet therapy should be minimized by avoiding DES or at least strictly limiting DES to those clinical and/or anatomical situations, such as long lesions, small vessels, diabetes, etc where a significant benefit is expected as compared to BMS Sometimes even the plain old balloon angioplasty should be considered when the angiographic result after balloon angioplasty is acceptable and in some cases also coronary artery bypass graft (CABG) might be fa- What to if patient needs CABG or staged PCI procedure? There is only limited experience on CABG during therapeutic oral anticoagulation or timing of cessation of OAC before surgery In the light of this limited information, bridging therapy with LMWHs or UFH is recommended for AF patients under long-term OAC referred for CABG (14, 106) However, clear protocol for warfarin cessation and bridging for cardiac surgery is lacking It is possible that poorly managed warfarin cessation can increase bleeding after coronary bypass surgery, since preoperative warfarin use has been cited as a risk factor for increased postoperative haemorrhage if warfarin is stopped within seven days before surgery (117) Elective or urgent CABG is frequently performed in patients on dual antiplatelet therapy due to previous PCI or in patients with ACS Perioperative management of antiplatelet therapy is problematic in view of the long elimination time required for the antiplatelet effect and individualised balancing between the increased perioperative bleeding risks and proven antithrombotic benefits caused the drugs In the CURE trial analyses, exposure to clopidogrel within five day before CABG increased the risk of major bleeding 50% and later retrospective analyses have shown the risk be comparable even when using off-pump surgery (42) Later retrospective analyses have, however, suggested that CABG during dual antiplatelet therapy is safer than previously thought and in a recent large single-centre cohort clopidogrel within five days before CABG did not increase the risk of reoperation, blood transfusion, or haematocrit drop ≥15% (118) In view of this limited information aspirin is recommended to be continued throughout the perioperative period in patients who require CABG within six weeks after stent placement of BMS and within 6–12 months after DES implantation even in patients on OAC In patients scheduled for elective CABG, it is common policy to interrupt clopidogrel at least five days before CABG, unless the risk of interruption is deemed unacceptable high In patients with ACS, the risks of delaying the surgery and withdrawing the evidence-based antiplatelet therapy should be balanced against the bleeding risks of ongoing dual antiplatelet therapy during CABG In case of emergent CABG in ACS whilst anticoagulated with OAC, fresh frozen plasma and vitamin K administration Consensus Document of the ESC Working Group on Thrombosis tially associated with bleeding or thrombotic events were reported: PCI in the setting of acute coronary syndrome (15/18), use of a GPI (12/18), no use of anticoagulation (12/18), use of DES (11/18), radial or femoral access site (7/18), and use of a closure device for femoral access patients (4/18 studies) might be needed before CABG to reverse anticoagulation, and UFH started During revascularisation by CABG, the opportunity to treat AF by surgical measures (e.g occlusion of left atrial appendix or surgical ablation by Cox-Maze or radical Maze) during the surgical procedure could be considered Staged PCI is not an issue when performing all the procedures during uninterrupted therapeutic OAC Repeated bridging therapy during staged operations is likely to lead to instability in the effective anticoagulation level Hence, the preferential strategy is probably the uninterrupted strategy Therefore, in the case of staged procedure, each procedure will be performed whilst being anticoagulated with an OAC Factors associated with bleeding in published reports of PCI in OAC patients The following factors were associated with increased bleeding risk in at least one of the published series on PCI in OAC patients − “Triple therapy” using an oral anticoagulant and dual platelet inhibition, most often aspirin and clopidogrel, in the earlier studies also aspirin plus ticlopidine (83, 97) − oral anticoagulation when compared to non-anticoagulated patients (59) − use of a GP IIb/IIIa inhibitor (83, 123), − left main or three-vessel disease (83), − older age (e.g >75 years) (59), − female gender (123), − smoking (123), − chronic kidney disease (83), and − a high INR value (> 2.6) (123) Systematic review of published data on anticoagulated AF patients with ACS +/- undergoing PCI/stents As part of the systematic review for this consensus document, we reviewed what other published guidelines have stated in relation to this topic A summary of recommendations has been depicted in Supplementary Table (available online at www.thrombosisonline.com) In addition, radial access was associated with less access site bleeding events in a recent cohort study of PCI “all-comers” (90) Interestingly, femoral closure devices were not well associated with reduced bleeding events: of the devices used in that study, only one (a fibrin plug) appeared to reduce access site bleeding (90) An earlier meta-analysis of femoral closure devices suggested no prevention of access site bleeding with one device and even an increase of bleeding events with another (older) device (128) 4.1 Review of published data on patients undergoing PCI who are either on oral anticoagulation or have AF In a systematic review of published data on patients undergoing PCI who are either on oral anticoagulation or have AF as part of this consensus document, we identified 18 studies that reported outcomes of anticoagulated and/or AF patients undergoing PCI (57, 60, 83, 97, 98, 99, 110, 119–127) (see Supplementary Tables (a) and (b) available online at www.thrombosis-online.com) These reported on approximately 3,500 patients The patients in some of the publications certainly overlap, so that the number of published patients is probably slightly lower Most publications reported retrospective analyses of single-center consecutive patient series receiving PCIs in different settings One report stratified patients to anticoagulation withdrawal or to continuation of anticoagulant therapy by the perceived need for anticoagulation based on prosthetic valves, recent presence of thrombus, recent pulmonary embolism, low ejection fraction or large atria, or prior stroke (127) The data are heterogeneous, and more so are the reporting of clinical parameters associated with thrombotic or bleeding events Outcome of PCI in OAC or AF patients Major long-term outcomes, usually assessed after one year or a few months of follow-up, were reported as follows: Death occurred in 12% of the patients, major bleeding events in 6%, stent thrombosis in 2%, stroke in 4%, myocardial infarction in 7% (nine studies) The combination of all MACE was only reported in five publications and is therefore not summarised in this analysis Event rates in trials that compared different antithrombotic regimes after stenting We also assessed similar information in the main publications of four of the major early PCI trials in which the optimal antithrombotic therapy after PCI with stenting was investigated, often by comparing anticoagulation arms and/or patient arms without a thienopyridine (i.e clopidogrel or ticlopidine) (7, 129–131) These trials reported on a total of 3,008 patients The major outcomes of these trials and the patient characteristics are summarised in Table The main outcome of these trials is that dual platelet inhibition is required to prevent stent thrombosis after PCIstenting In the context of this document, it is well worth noting that factors associated with bleeding were often not reported (Table 2) Also, major complication rates were lower in these trials, while reported bleeding rates were higher, albeit in the setting of a controlled clinical trial with rigorous follow-up Interestingly, the rate of major cardiovascular complications Reporting of potential factors involved in bleeding or thrombotic events during PCI In a first step, we analysed the number of studies that reported several of the known factors associated with bleeding and/or thrombotic events This analysis summarizes which factors were estimated as relevant by the investigators and authors, and by exclusion identifies factors that may be neglected by some In descending order, the studies reported on the following known clinical factors associated with bleeding or thrombotic events: female sex (15/18 publications), presence of AF (15/18 publications), diabetes or hypertension and use of a stent (14/18 publications), prior stroke (9/18), renal dysfunction (6/18), and a history of bleeding events (3/18) In addition, the following procedural details poten- Consensus Document of the ESC Working Group on Thrombosis and the rate of stent thrombosis was similar in these trials when compared to the MACE and stent thrombosis rate in published OAC-PCI cohorts Similarly, and a bit surprisingly, the rate of major bleeding events was not that markedly elevated in the OAC patients when compared to the PCI study patients (Table 2) The rates of severe outcomes, namely stroke and death, in contrast, was markedly higher in the OAC patients than in the PCI study patients, again highlighting the relevance of thrombotic (rather than bleeding) events for survival in patients that require OAC lesions, small vessels, diabetes, etc where a significant benefit is expected as compared to BMS and triple therapy (OAC, aspirin, clopidogrel) used for four weeks following PCI with BMS in patients with AF and stable coronary artery disease; this should be followed by long-term therapy (12 months) with OAC plus clopidogrel 75 mg daily or alternatively, aspirin 75–100 mg daily, plus gastric protection with either PPIs, H2-receptor antagonists or antacids depending on the bleeding and thrombotic risks of the individual patient) (Class IIa, Level of Evidence: B) (ii) Clopidogrel 75 mg daily should be given in combination with OAC plus aspirin 75–100 mg daily for a minimum of one month after implantation of a BMS, but longer with a DES [at least three months for a ‘-limus‘ (sirolimus, everolimus and tacrolimus) type eluting stent and at least six months for a paclitaxeleluting stent] following which OAC and clopidogrel 75 mg daily or alternatively, aspirin 75–100 mg daily, plus gastric protection with either PPIs, H2-receptor antagonists or antacids may be continued (Class IIa Level of Evidence: C) Expert consensus recommendations of a practical, pragmatic approach to management of patients with AF who need anticoagulation with Vitamin K antagonists [Table 3] 5.1 Elective (i) In elective PCI, DES should be avoided or strictly limited to those clinical and/or anatomical situations, such as long Table 2: Summary of the published clinical, procedural and outcome information on anticoagulated patients or AF patients undergoing PCI For abbreviations, see text For comparison, the same information – if available – is also given from four major PCI studies that included an OAC arm Bold numbers indicate that there is a relevant numerical difference between the groups All of these differences favour bleeding in the OAC cohort studies It is well worth noting that bleeding rates were comparable between these studies, while other outcomes, mainly stroke and death, were more prevalent in the OAC reports These differences may be due to selection bias (controlled trials vs cohort studies) and probably in part reflect that populations at low risk for death or stroke were included in the early controlled PCI studies [*indicates inferred information] Reports on PCI in anticoagulated patients (n=18 publications) Percent of patients Number of studies reporting data Patients on OAC 72% 18 Patients with AF 67% 14 Acute coronary syndrome 82% 15 Radial access 20% Femoral access 80% Closure device 31% GPI inhibitor 36% 12 POBA only 1% 12 Stent 98% 13 Drug-eluting stent 46% 11 PCI studies including OAC and antiplatelet arms (n=4 publications) Percent of patients Number of studies reporting data 41% 45% 100%* 0%* Mean age (yrs) 69,0 16 71,0 16 Females 28% 15 9% Prior stroke 13% 2% Diabetes 32% 14 9% Hypertension 71% 14 16% Heart failure 23% 9% Renal dysfunction Prior relevant bleed 26% No OAC 47% 11 50% 12% 1% Major bleed n 6% 13 6% Stent thrombosis 2% 10 2% Stroke 4% 0% Infarctions 7% 3% Major Outcomes Death (n) Consensus Document of the ESC Working Group on Thrombosis Table 3: Recommended antithrombotic strategies following coronary artery stenting in patients with atrial fibrillation at moderate-to- high thromboembolic risk (in whom oral anticoagulation therapy is required) Haemorrhagic risk Clinical setting Stent implanted Recommendations Elective Bare metal month: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≥100 mg/day + clopidogrel 75 mg/day + gastric protection lifelong: warfarin (INR 2.0–3.0) alone (-olimus group) to (paclitaxel) months: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≥100 mg/day + clopidogrel 75 mg/day; Elective up to 12th month: combination of warfarin (INR 2.0–2.5) + clopidogrel 75 mg/ day* (or aspirin 100 mg/day); Drug eluting Low or intermediate lifelong: warfarin (INR 2.0–3.0) alone months: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≥100 mg/day + clopidogrel 75 mg/day; ACS Bare metal/drug eluting up to 12th month: combination of warfarin (INR 2.0–2.5) + clopidogrel 75 mg/ day* (or aspirin 100 mg/day); lifelong: warfarin (INR 2.0–3.0) alone Elective to weeks: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≥100 mg/day + clopidogrel 75 mg/day; Bare metal# lifelong: warfarin (INR 2.0–3.0) alone weeks: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≥100 mg/day + clopidogrel 75 mg/day ; High ACS Bare metal# up to 12th month: combination of warfarin (INR 2.0–2.5) + clopidogrel 75 mg/ day*(or aspirin 100 mg/day); mg/day); lifelong: warfarin (INR 2.0–3.0) alone * combination of warfarin (INR 2.0–3.0) + aspirin = 100 mg/day (with PPI, if indicated) may be considered as an alternative # drug eluting stents should be avoided INR = international normalized ratio; PPI = proton pump inhibitors; ACS = acute coronary syndrome (iii) Where OAC patients are at moderate-high risk of thromboembolism, an uninterrupted anticoagulation strategy can be the preferred strategy and radial access used as the first choice even during therapeutic anticoagulation (INR 2–3) This strategy might reduce periprocedural bleeding and thromboembolic event during bridging therapy (Class IIa Level of Evidence: C) (iv) When the procedures require interruption of OAC for longer than 48 hours in high-risk patients, UFH may be administered LMWH (enoxaparin, dalteparin) given by subcutaneous injection is an alternative, although the efficacy of this strategy in this situation is uncertain There may actually be an excess bleeding risk associated with such “bridging“ therapies, possibly due to dual modes of anticoagulation in the overlap periods In many patients, performing PCI after a short interruption of oral anticoagulation (e.g at an INR close to the lower border of the therapeutic range) will be adequate (Class IIa Level of Evidence: C) (v) When OAC is given in combination with clopidogrel and/or low-dose aspirin, the dose intensity must be carefully regulated, with a target INR of 2.0–2.5 (Class IIb, Level of Evidence: C) 5.2 NSTE-ACS including unstable angina and NSTEMI (i) Following presentation with a NSTE ACS with or without PCI in patients with AF, dual antiplatelet therapy with aspirin 10 + clopidogrel is recommended, but in an AF patient at moderate-high risk of stroke, anticoagulation therapy should also be given/continued (Class IIa, Level of Evidence: B) (ii) In the acute setting, patients are often given aspirin, clopidogrel, heparin (whether UFH or a LMWH, enoxaparin) or bivalirudin and/or a GPI Given the risk of bleeding with such combination antithrombotic therapies, it may be prudent to stop OAC therapy, and administer antithrombins or GPIs only if INR ≤2 Many such patients will undergo cardiac catheterisation and/or PCI-stenting, and DES should be avoided or be strictly limited to those clinical and/or anatomical situations, such as long lesions, small vessels, diabetes, etc where a significant benefit is expected as compared to BMS However, in anticoagulated patients at very high risk of thromboembolism, uninterrupted strategy of OAC can be the preferred strategy and radial access used as the first choice even during therapeutic anticoagulation (INR 2–3) This strategy might reduce peri-procedural bleeding and thromboembolic event during bridging therapy (Class IIa Level of Evidence: C) (iii) For medium to chronic management, triple therapy (OAC, aspirin, clopidogrel) should be used in the short term (3–6 months), or longer in selected patients at low bleeding risk In patients with a high risk of cardiovascular (thrombotic) complications [e.g patients carrying a high GRACE or TIMI risk score], long term therapy with OAC may be combined with clopidogrel 75 mg daily (or alternatively, aspirin 75–100 mg Consensus Document of the ESC Working Group on Thrombosis daily, plus gastric protection with either PPIs, H2-receptor antagonists or antacids) for 12 months (Class IIa Level of Evidence: C) (iv)When OAC is given in combination with clopidogrel and/or low-dose aspirin, the dose intensity must be carefully regulated, with a target INR of 2.0–2.5 (Class IIa Level of Evidence: C) 5.3 Primary PCI (i) In the acute setting following presentation with acute STEMI with primary PCI in a patient with AF, patients are often given aspirin, clopidogrel and heparin (UFH) Where patients have a high thrombus load, bivalirudin or GPIs may be given as a ‘bail out’ option As an alternative to heparin + GPI, bivalirudin can be used Mechanical thrombus removal (e.g thrombus aspiration) is encouraged Given the risk of bleeding with such combination antithrombotic therapies, it may be prudent to stop OAC therapy Ideally, GPIs, or bivalirudin, would not be considered if INR is >2, except in a ‘bail out’ option (Class IIa, Level of Evidence: C) (ii) The dose of peri-procedural heparin may be adjusted to achieve a low-therapeutic activated clotting time (ACT 200–250 seconds in patients receiving a GPI, or 250–300 seconds in patients not receiving a GPI), where available (Class IIa, Level of Evidence: C) (iii) If the presentation with acute STEMI occurs, radial access for primary PCI is probably the best option to avoid procedural bleeding depending on operator expertise and preference (Class IIa, Level of Evidence: B) (iv)For medium- to long-term management, triple therapy (OAC, aspirin, clopidogrel) should be used in the short term (3–6 months), or longer in selected patients at low bleeding risk, followed by more long-term therapy (up to 12 months) with OAC plus clopidogrel 75 mg daily (or alternatively, aspirin 75–100 mg daily, plus gastric protection with either PPIs, H2-receptor antagonists or antacids) (Class IIa Level of Evidence: C) 5.4 What to in patients at high risk of bleeding (i) Arterial access via the radial route should be used especially during therapeutic anticoagulation (INR 2–3) Fondaparinux is an alternative to enoxaparin (in non-STE-ACS, but not for acute interventions) but limited data are available in anticoagulated patients (ii) Bivalirudin is an alternative to heparin + abciximab peri-PCI, but there are no available data in anticoagulated patients (iii) Medium to long-term management should possibly avoid, and anyway strictly limit DES to those clinical and/or anatomical situations, such as long lesions, small vessels, diabetes, etc where a significant benefit is expected as compared to BMS Triple therapy should be used for 2–4 weeks, followed by OAC monotherapy In selected patients at high risk for cardiovascular events and for bleeds, clopidogrel 75 mg/day may be added despite a high bleeding risk of the anticoagulant-clopidogrel combination (also see recommendation 5.6.) 11 5.5 Application to non-AF populations i.e general anticoagulated populations The recommendations for non-valvular AF patients largely apply to ‘general’ anticoagulated populations, with some notable exceptions (i) Where patients have AF and a prosthetic mechanical heart valve, such patients would be at substantial risk of thromboembolism and/or prosthetic valve thrombosis during interruption of anticoagulation These patients should undergo percutaneous procedures during anticoagulation in the low therapeutic range (Class IIa Level of Evidence: C) (ii) Similarly, patients with recent (3–6 months) or recurrent venous thromboembolism would be at risk of recurrent events should anticoagulation be interrupted Arterial access via the radial route has to be preferred in such patients, especially during therapeutic anticoagulation (INR 2–3) depending on operator expertise and preference (Class IIa Level of Evidence: C) (iii) Medium to long-term management would be as described above, for elective and acute settings 5.6 Miscellaneous (i) In patients with stable vascular disease (e.g with no acute ischaemic events or PCI/stent procedure in the preceding one year), OAC monotherapy should be used, and concomitant antiplatelet therapy should not be prescribed (Class IIa, Level of Evidence: B) (ii) In patients with AF younger than 65 years without heart disease or risk factors for thromboembolism (essentially lone AF, CHADS2 score=0), the risk of thromboembolism is low without treatment and the effectiveness of aspirin for primary prevention of stroke relative to the risk of bleeding has not been established Thus, such patients would not need OAC therapy, and management for elective PCI-stenting can follow routine management strategies (Class IIa, Level of Evidence: B) (iii) Following acute presentations with ACS, aspirin + clopidogrel should be used for 12 months, irrespective of whether PCI-stenting is performed, following which single antiplatelet therapy (e.g aspirin) can be used, as indicated by guidelines (Class IIa, Level of Evidence: C) Areas for further studies Current recommendations in this consensus document are largely based on limited evidence obtained from small, singlecenter and retrospectively analyzed cohorts Thus, there is a definite need for large scale registries and prospective clinical studies appear to determine the optimal antithrombotic management of patients with AF at intermediate or high thromboembolic risk undergoing coronary interventions Until then, the debates over the optimal antithrombotic management strategy for AF patients presenting with acute coronary syndrome and/or undergoing PCI-stenting is likely to continue (132, 133), especially in the presence of stroke risk factors – and whether AF is paroxysmal, persistent or permanent (134, 135) This scenario will change with the availability of more potent antiplatelet agents (e.g prasugrel, etc) that in current ACS trials shows im- Consensus Document of the ESC Working Group on Thrombosis proved efficacy but greater bleeding risk, when compared to clopidogrel (136) However, data on prasugrel in anticoagulated patient populations are lacking A prospective, multi-center registry AFCAS (Management of patients with Atrial Fibrillation undergoing Coronary Artery Stenting), aiming at prospectively evaluating the antithrombotic strategies currently adopted in this patient subset, and at investigating the potential benefit or harm of OAC and/or antiplatelet treatments, has been launched in several European countries The first results of this study (expected in late 2009) will hopefully contribute to shed light on this common issue (137) Another registry sponsored by the Working Group on Thrombosis, the LASER registry has just started The ISAR-TRIPLE trial will give an answer to the hypothesis that reducing the duration of clopidogrel therapy from six months to six weeks after DES implantation is associated with improved clinical outcomes in patients on acetylsalicylic acid and an oral anticoagulant (127) The What is the Optimal antiplatElet and anticoagulant in patients with oral anticoagulation and StenTing (WOEST) study (139) will assess the hypothesis 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